The role of Vitamin D in rosacea/facial flushing

As if a red burning face wasn’t enough inconvenience to deal with, a rosacea patient often also has to face the endless seeming stream of skin triggers and possible treatment options.  Sunlight is among the top rosacea flare triggers. And research shows that the majority of rosacea patients have low vitamin D3 levels. What does this all mean for us, and do vitamin D supplements help or harm rosacea?

Facial flushing, burning and general redness can be very difficult to tackle. Luckily there are forums where fellow patients write about their experiences, but it can be a daunting task to weed through the enormous amounts of posts. One conclusion that all members seem to agree on however, is that there isn’t a golden rule treatment wise. Unfortunately. There isn’t even a common agreement on the cause of rosacea. The papular subtype has most likely a bacterial component to it or is linked to a demodex skin mite reaction, but for vascular rosacea this seems less likely. The opinions vary, but I think personally that at least a percentage of the vascular cases stem from (immune related) inflammation in the body. In my own case there is an autoimmune response in other parts of the body (bowel, blood vessels, skin). I talked to a host of pretty specialized dermatologists over the years and none of them believe that demodex mites play a dominant role in the rosacea cases that suffer primarily from facial flushing and redness. Some people that I communicate with through forums, mention that when they take anti inflammatory medication - sometimes for something totally different - their flushing and redness reduce. For many of us, it most likely comes down to symptom treatment and avoidance of triggers as much as possible.. Although sometimes rosacea can be brought in remission. When it comes to anti-inflammatory medication, there are countless herbs, ointments, vitamins, probiotics and natural products that have potential to help rosacea. This post will examine the role of vitamin D3 levels in rosacea and whether adding vitamin D through pills or special narrowband light devices can improve the inflammation levels and rosacea symptoms.

Vitamin D and rosacea

Everybody needs vitamin D for strong bones. It stimulates the absorption of calcium. Muscles need vitamin D to function correctly and nerves use it to transmit messages between the brain and other organs and body parts. The immune system needs vitamin D to combat viruses and bacteria, also in the skin. It maintains the body’s immunity against diabetes, various types of cancers, muscle wasting, heart disease, osteoporosis and so on. Vitamin D3 is actually a hormone and there are very few foods that contain this vitamin. It can be made by the body through the absorption of sun on the skin. A study that was published in the "Journal of Allergy and Clinical Immunology" showed that vitamin D stimulates the production of a peptide in the skin, cathelicidin, that is effective against microorganisms and that fights infections. It helps protect the skin in that respect. Studies indicate for instance that people with eczema have a lack of cathelicidin, and in small scale studies it appeared that adding vitamin D sometimes alleviates symptoms. More studies are needed however for a definitive confirmation, but the results so far are promising. (Source). The relationship between vitamin D and rosacea is a more complicated one. Initial studies showed that rosacea patients have in fact elevated levels and abnormal types of cathelicidin in their skin. Based on these findings one would be inclined to say that elevating vitamin D levels should lead to more cathelicidin and therefore even more symptoms. These researchers believe that rosacea patients are more helped with medication that blocks the production of cathelicidin in the skin (one of the suspected reasons why doxycycline works for quite a lot of rosacea patients). Note that the cause of rosacea has been proposed as over-production of the cationic cathelicidin peptide LL-37. Let’s focus some more on these cathelicidins.

Abnormal cathelicidins in the skin of people with rosacea
In 2007, Dr Richard Gallo of the University of California was the one who discovered that cathelicidins and the proteolytic enzymes that activate cathelicidins in the skin are abnormal in people with rosacea. I found this publication and this one as well. In an online article this claim was made:

"New studies show that vitamin D, particularly vitamin D3 can provide relief from skin inflammatory skin ailments such as rosacea."

Cathelicidins are antimicrobial peptides and the enzymes in the skin of rosacea sufferers cause them to produce these peptides in an abnormal form. Too many, and too active. This revelation turned out to be a breakthrough and sent a whole bunch of scientists off in a new direction. Gallo himself has now done follow-up research and he thinks that rosacea patients' innate immune systems, overall, are abnormal. A study in Belgium has made a connection between the regulation of cathelicidins and vitamin D. This is because there is what they call "a previously unknown and unexpected link between innate immunity and the vitamin D system". Interestingly, one in four Americans are vitamin D deficient and medical researchers believe that low levels of vitamin D are responsible for a whole range of ills, from muscular weakness to autism. Ok, I am lost now with these conflicting studies and conclusions.. Will vitamin D help regulate the immune system and therefore normalize the quality and quantity of those cathelicidins in rosaceans or not?! 

Cathelicidins and Peptide LL-37
This is more recent research, which clearly names vitamin D pathways in the skin as a direct route for skin inflammation, redness and blood vessel dilation. When our rosacea skin gets exposed to direct sunlight and starts making vitamin D, there are special body cells sent to work; cathelicidins. In the human body they play a crucial role in the immune defense against bacterial infections. Wikipedia states: 

"Patients with rosacea have elevated levels of cathelicidin." And when wiki states that "Excessive production of LL-37 is suspected to be a contributing cause in all subtypes of Rosacea", it cites this research paper, stating that normal skin has three ways to protect itself from bacteria from the outside world, trying to get in. First you have the top layer of the skin, which forms a shield (if the skin barrier functions as it should do!). This outer layer of skin has special cells that work as part of the bodies immune system, signalling when substances enter the skin that do not belong to the body itself, for instance bacteria. They signal to the other cells of the danger once a bacteria does try to invade the skin. If this happens, the bodies immune system sends specific cells to the surface that are causing inflammation, trying to force out or kill the invading bacteria. One of these specific cells are antimicrobial peptides (AMP's), of which there are to date several hundred different types found. They can kill bacteria by messing with their cell membranes, but also fungi and viruses. So they are part of our skin's little army, if you will. Cathelicidins are part of this AMP system. The precise cathelicidin that's involved in AMP is called Cathelicidin antimicrobial peptide (CAMP). And Cathelicidin LL-37 belongs to the CAMP family. It can break up bacteria, fungi and viruses that land on the skin. But it can also give off an "alarm" which brings the skins army into action, causing inflammation to eradicate the invading organisms. They mainly get activated and detectable in the skin once there is skin injury. When all is normal and the skin functions as normal, they are hardly to be found in the upper skin. But Cathelicidin LL-37 can also trigger the immune system. Thus, it plays an important, dual, role in the immune function of the skin. And when this LL-37 peptide does not function as it should, it can in fact have the reverse effect on the skin and cause skin inflammation. And also allow bacteria to infect the skin. The scientists found that in rosacea skin, cathelicidin LL-37 often does not function as it should, and what is worse, they found that rosacea skin has much higher levels of this LL-37:

"Indeed, cathelicidin is strongly increased lesional skin in rosacea compared to the skin of non-affected individuals."

Rosacea in general results in chronic inflammatory and vascular response [redness, p&p's, blood vessels dilating more than they should]. The "alarm" function of LL-37 is off in rosacea skin, meaning it calls for the help troops to come in when there is, in fact, no real threat... No invading bacteria to fight off, no fungi and no viruses. And instead, it stimulates inflammation of the (rosacea) skin and dilation of the blood vessels (thanks to the help of nitric oxide and EDHF):

 "In rosacea increased levels of the vasoactive and inflammatory host-defense peptide LL-37 and its proteolytic peptide fragments are found which can be explained by an abnormal cathelicidin production and pathologic protease activity."

The scientists got confirmation about all this, when they injected these specific cathelicidins in the normal skin of mice. They all developed rosacea-like skin symptoms then. The problem is now that scientists do not understand yet WHY rosacea skin has these higher numbers of cathelicidins, although they found 3 different 'portals' so to speak, through which the extra peptides were produced. They were retinoid-, vitamin D- and cytokine-activated. The vitamin D-pathway could explain why rosacea is only present on the face normally, and not on the rest of the body: the body is usually covered up and it is the face that gets the most sun-exposure and therefore the most vitamin D. And therefore, the more vitamin D is made in the skin, the more Cathelicidin LL-37 (and thus the more disrupting inflammation and vasodilation). But this is only a small part of the puzzle, as many people with rosacea shun the sun and protect their faces from sunlight at all times. Also, many with rosacea have low levels of vitamin D in fact. 

But scientists also found that cathelicidins could be triggered by keratinocytes (outer layers of skin cells), which have nothing to do with vitamin D. They found that the outer skin cells themselves can signal the making of more Cathelicidin LL-37 when they are injured, get exposed to UV radiation, or when the outer layer of the skin gets disrupted in any way. Skin Stress, one could call it. Ánd, interestingly: skin stress includes heat. "This again could explain why rosacea patients often report on unspecific triggers (e.g. heat) which would mediate their proinflammatory activities through ER stress and cathelicidin induction." So when our rosacea skin gets triggered by heat, for instance you enter a very warm room, then this heat touching the skin will cause stress in the outer layer of the skin, sending of "alarm signals", which stimulate the LL-37 and other peptides to come into action and create.... inflammation. The fact that rosacea skin on average has a higher surface temperature than normal skin is not really helping here. Physical stress can trigger the same response by the way, as well as alcohol  consumption: Inflammation.. Demodex mite infection can also trigger the skin to make these inflammation alarm reactions, as demodex mites can cause increased protease activity in rosacea skin, which does the alarm bells of  Cathelicidin LL-37 go off again. Which in turn triggers inflammation, redness and blood vessel dilation in the skin. This is probably why oral and topical antibiotics (tetracyclines for instance), azelaic acid and retinoids can work for rosacea: they directly interfere with this proinflammatory system and reduce the inflammation or stop it from being formed altogether. So antibiotics can work for rosacea, not because of their ability to kill off bacteria, but instead because of how they reduce inflammation. And the same goes for anti-demodex treatment. which can take away the prime trigger for LL-37-related skin inflammation IF you have a demodex mite infection.

Try to avoid direct sunlight on your face. Vitamin D from sun is a direct trigger for LL-37-mediated inflammation 
and blood vessel dilation of rosacea skin. You can bronze the rest of your body, just not your face if you want to calm down rosacea-inflammation. (And now that I am at it, could this perhaps explain why so many people flare up from vitamin D supplements?? I get beyond beet red from them and never understood why. Maybe here we have it, the explanation). Certain supplements and herbs can also act as anti-inflammatories. Check my blog post about them here. Think of supplements like turmeric/ curcumin or boswellia for instance. If you want to know even more detailed information about how exactly this mechanism works on cellular level, I advise you to go to this science article and scroll down to the section Rosacea. You can also read more in this scientific article.

Many skin conditions can be caused or worsened by the sun, ultraviolet (UV) radiation and oxidative stress. 
The most common source of vitamin D3 is of course the sun. Sun provides us with vitamin D3 through the way our skin breaks down the sun. However, UV radiation from the sun can not only cause skin burning, but also premature ageing and wrinkling (not to mention skin cancer..). Sun exposure is near the top of the list of rosacea triggers and causes for rosacea progression, according to the National Rosacea Society (NRS). The sun’s damaging UV rays can cause many rosacea symptoms and long-term flares, but the damage to blood vessels throughout the face is one of the most important problems with regards to progression — often causing mild rosacea sufferers to eventually progress into the moderate-to-severe stages. Everyone knows that to avoid sun damage in the skin, we'd best put a sunscreen on or to avoid having your skin directly in the sunlight altogether. However, that doesn't mean that we aren't subjected to UV radiation inside the home at all. UV light from the sun also reaches our skin through windows, both in the home, workplace or in your car. It's ideal to use a sunscreen or moisturizer with a minimum SPF of 30. Like with the chronic illness lupus, some people with rosacea may also have light sensitivity, to the point that sunlight worsens the inflammation and redness, as does fluorescent lighting for some very sensitive patients. Read more about this in my blog post "Could computer screens (or phone/TV ones) worsen rosacea?" In fact, sun exposure and sunburn are even a known cause (one of many possible causes!) of rosacea.  But there are also many people with rosacea who don't find sunlight a trigger, and for others their skin even clears up from sun. I think it's important to remember that rosacea comes in different subtypes:

Subtype 2, with skin outbreaks and bumps, can sometimes handle sun much better than subtype 1 with redness and flushing. It depends per person and is also depending on your skin type; the more pale you are, the less chance that your rosacea skin improves from sun. Darker skin tones have more melanin, which makes the skin thicker and makes it more difficult for the sun rays to reach the lower layers of the skin, where damage is done and where the blood vessels lie. But in fair skinned people, the sun does reach the lower levels easily and can do harm there. In fact, it can worsen skin inflammation. Sun can also dilate blood vessels and especially the small superficial blood vessels in your face (particularly in fair skinned people, whose skin is more easily penetrable for the damaging sun rays), and cause or worsen rosacea. Ultraviolet (UV) radiation -- a component of sunlight -- leads to the production of vascular endothelial growth factor (VEGF), a substance that has been linked to the development of visible blood vessels (telangiectasia).  UV rays not only dilate existing blood vessels but can also stimulate the uncontrolled overgrowth of new blood vessels (angiogenesis) in the skin, and trigger those new blood vessels to grow much closer to the surface. The heat from the sun might also dilate your existing blood vessels and cause a flare. Even cloudy days do not protect you from the sun's UV radiation, so either protect your skin with sunscreen or moisturizer with SPF, or wear a hat like I do and keep your face in the shade (and realize that reflecting sunlight from walls and pavements can still reach your face!).

So summarized

- Within 20 to 30 minutes of exposure to the sun’s UV rays, direct UV absorption into the blood vessel walls can cause the collapse of affected blood vessels and can cause irreversible damage to the structure of the blood vessel. This type of damage often results in “broken blood vessels” or telangiectasia
- Short term sun exposure also triggers cathelicidin-related inflammation in the skin and the blood vessels.
- Short term sun exposure stimulates new (over)growth of facial blood vessels known as angiogenesis. This is central to rosacea progression and once grown they are permanent fixtures in the facial skin.
- Short term exposure causes blood vessels to grow much closer to the surface. Oftentimes it will cause blood vessels to grow into the upper epidermis which is normally does not have such superficial blood vessels. This is a serious side-effect because these superficial blood vessels are now left nearly unprotected and much more prone to environmental damage.

- Short term sun exposure increases the number of mast cells around blood vessels.  Mast cells contain dozens of potent blood vessel dilators – thus, more mast cells usually results in increased facial redness and flushing.
- Short term sun exposure turns on inflammatory enzymes like collagenase and elastase. These two enzymes break down the skin’s architecture and eat away at blood vessels like “PAC MEN”. Short term sun exposure stimulates damaging enzymes such as Matrix Metalloproteinases, one of the hottest subjects in rosacea research and treatment. Each sun exposure thins the protective epidermis, which in turn, results in more damage to blood vessels over time. (Source)

How about sun UV and oxidative stress?  

Some antioxidants are said to have potential to protect against some skin conditions, including skin aging and skin cancers. UV light can directly cause DNA damage, as well as start a cascade of oxidative stress and related signaling, leading to mutation and irreparable damage to the cells. The dermis contains connective tissues of the skin, nerve endings, sweat glands and hair follicles. The epidermis must be a weather- and waterproof layer in order to protect the body. Because of the large amount of cells and structures within the skin and because the skin is the first line of defense, it is not surprising that many different things can go wrong and cause a variety of skin diseases. In normal, unstressed cells there is a constant production of reactive oxygen from the mitochondria, which is balanced by the production of antioxidant enzymes in the cell, such as superoxide dismutase (SOD), catalase and glutathione peroxidase. When a cell comes under stress, this balance is interrupted, and the reactive oxygen species can overwhelm the cell and lead to a change in normal cellular behaviours. Oxidative stress can be caused by different things, including cigarette smoke, extreme temperature change and exposure to UV radiation. In fact: exposure to UV radiation is one of the most important factors in many skin disorders and diseases, including aging and cancer.

There are three main types of UV radiation; UVA, UVB and UVC. UVA is the longest wavelength and is thought to be responsible for many skin conditions including skin aging and the onset of skin cancer. UVB, a mid-range wavelength, is thought to contribute mostly to the development of skin cancer, although it has been shown to play a role in aging and other skin damage. UVC is the shortest wavelength that does not usually penetrate the atmosphere. However, UVC can also play a role in DNA damage. In many cases, the visible signs of skin aging, such as wrinkling, dryness and discoloration, are caused by or worsened by UV exposure. Additionally, other skin conditions that can result from chronic sun and UV exposure, such as actinic keratosis, have been linked with increasing an individual’s risk of skin cancer, which can also be induced by UV exposure. UV radiation can also cause oxidative stress in skin cells, which is thought to be another contributor to skin disease and skin carcinogenesis. Several antioxidants, including vitamins C, E, and the green tea polyphenol (−)-epigallocatechin-3-gallate (EGCG), have been shown to have protective effects against skin conditions. A number of studies have shown that resveratrol also possesses promise against certain skin conditions, including skin cancer, in preventive as well as in therapeutic settings. Try to avoid sun exposure on your face when you have rosacea. You will avoid sun-induced worsening of your rosacea, and as a bonus will develop less wrinkles (unless you smoke of course, tsk tsk tsk in that case). My body-bronzing daily set-up when the sun shines: face in the shade, covered by a hat and body in the sun for about 20-30 minutes a day.

Rosacea, Cathelicidin and Vitamin D
As explained above, there is a link between vitamin D and rosacea, which can be explained by cathelicidin dysfunction. Normally, our bodies produce antimicrobial peptides or AMPs, which protect our skin against infection. Cathelicidin is an antimicrobial peptide that is found in the skin and it was found that individuals who do not produce or process cathelicidin properly are more likely to have rosacea. One of the ways with which cathelicidin can be regulated is (said to be) through the intake of vitamin D3 supplements, which was found to regulate cathelicidin in the skin, and therefore treat or manage inflammatory skin diseases such as rosacea. (Source)

I asked my dermatologist about this. He replied:
"Vitamine D is very important for calcium levels, especially in female elderly persons. It has immunosuppressive activities in higher levels, by multiple mechanismus, obviously in (auto-) immune diseases. There is no sufficient evidence for rosacea, but one should try it as a supplement for more than three months. To be prescribed by your generalist. Cathelicidin levels seem to be regulated by genetic processes, and may be disturbed in certain diseases. The Demodex mite plays a role in pustular rosacea of the elderly (very old discussion!). Should not be important for you."

Vicky has the same question and wrote on the rosacea forum: 
"My internist recommended I take 2000 mg Vit D per day. My D level is low; it is within the normal range but only by one number-the range starts at 33 and my level is 34. I read (but didn't completely understand) some of the Gallo research and it seemed to indicate that Vitamin D increases the cathelicidin production, which is bad for us, right? However, I talked to my derm and he said if the D level is too LOW it can also interfere with cathelicidin expression. He encouraged me to take the Vitamin D."  -   I myself consistently have low to very low vitamin D3 blood levels, and am deficient. Strangely enough even at the end of summer, when sporting a body tan (although D3 levels did slowly crept towards moderately low levels by then, instead of severely low). I still don’t fully understand the link between vitamin D and those cathelicidins, I am going with the opinion of both my dermatologist and my internist, who has kept stressing for the past 2 years that I should get my vitamin D levels up if I want to alleviate the auto-immune problems and if I want to get my inflammation-, T-cell- and ANA levels in the normal range. So: avoid direct sunlight on the face, but make sure to have normal vitamin D levels through sunbathing of the body. Last year I have been taking sun baths daily in the spring and summer. I made sure that I had full body exposure around noon, when the sun is at its strongest, for half an hour a day. Sun exposure at higher latitudes before 10 am or after 2 pm will, surprisingly, cause burning from UV-A before it will supply adequate vitamin D from UV-B. It means that sunning should ideally occur between the hours we have been told to avoid. Sunning between 10 am and 2 pm during summer months (or winter months in southern latitudes) for 20-120 minutes, depending on skin type and color, will usually form adequate vitamin D before burning occurs. I had my head in the shade and covered with a hat to avoid getting my cheeks burned and even used a small fan to not get overheated and flushed. It is important to not wear any sunscreen. That will block the formation of vitamin D by the sun. I guess it’s only an option for those who don’t burn easily. I noticed that I usually flushed for an hour or so after this session, but then I would get more pale and the next morning I would be less red as well. I developed a proper tan soon and my flushing and redness and inflammation seemed a lot calmer than in winter. So I will continue to do this in the spring and summertime from now on, if only to not fall back to a vitamin level of below 10 ng/mL (severely low, must be 50 or greater ideally) like last winter. The highest D3 level that was ever tested for me at the end of summer was 30 ng/mL, from memory. And I had really made an effort to bronze myself that summer. Now, there might be several factors at play here, since almost everybody gets worse in winter, with more extreme temperature changes etc. But I used a vitamin D lamp in winter and I do think I was a bit less bad than in other years. No miracle cure for me however, but I do think it improves matters a bit in my case. When I spent longer than this 30 minutes in the sun I got very overheated and overly flushed.

Dr. Art Ayers writes an interesting blog about inflammation and anti-inflammatory diets. He wrote about this topic to a rosacea patient
"Based on my understanding of rosacea and reports of rosaceans, I would say that diet-based inflammation and the gut changes that result from that diet, are the foundation of rosacea. I would be baffled at antibiotic treatment that was not supported by an anti-inflammatory diet, including probiotics. I would expect that your wife is also deficient in vitamin D. I would recommend that she have her serum vit D checked and adjusted with increasing doses of D3. More serious cases of rosacea exhibit flare ups in response to D3 or antibiotics." [..] "Sugar and starch definitely contribute to rosacea. Grain may contribute to common gluten intolerance and be a major source of gut problems that contribute to rosacea.” 

I personally found that taking vitamin D3 supplements of 1000 units or more made me flush
And I know from some rosacea friends that they had similar problems. I am always suspicious of possible ingredients that might trigger a response, so I usually opt for the organic version with little or no extra ingredients apart from the active ingredient and a vegetable capsule. But despite that, the supplements made me flush a lot, and long term as well. I think it might be related to me getting extra flushed from too much sun exposure as well. Small doses seem the only way forward in my case. There were similar reports on the forums. Many people tried the D3 supplements after Dan reported significant improvement from it, but not everyone had good results. I wonder if the high doses they took might be the reason for this. I will below give an evaluation of the outcomes of these forum threads (one counting more than 130 pages!). With regards to the vitamin D3 supplement pills, I did some reading and found that even people with normal skin mentioned facial flushing as a side-effect! That was very typical indeed. It might perhaps have something to do with the way the D3 supplement pills are digested and absorbed by the body.

The vitamin D lamp that I own is a UVB narrowband light device. It emits very narrow ranged UVB radiation and even one minute of skin exposure stimulates the body to produce vitamin D. I rather have my body make its own vitamin D than to rely on pill supplements that have to be digested in order to be absorbed etc etc. I use this lamp for a minute or two every other day during winter. It is made primarily for the treatment of psoriasis and eczema. But my rosacea seems to respond well to it, possibly because every time I did blood work, my vitamin D3 levels are very low. The UVB light can burn you, even though it is 'cold' light. When you use the lamp too long at a time, a red rash like a mild sunburn can appear on the exposed skin (I usually shine it on my arms or legs while covering my face and head with a towel or something). So it is key to not overdo it. It might be hard to believe that one single minute of lamp light is enough, but I discussed it with a laser dermatologist who works with these devices for his psoriasis patients, as well as with the manufacturer of the lamp. The laser derm stressed to not overdo it with the lamp and to start with 30 seconds one both arms (so two times 30 seconds). He mentioned that it is best to expose skin to the lamp that normally tans the easiest or that has the best tan already; that skin will produce far more vitamin D than white, unexposed skin will do. (However, I read conflicting information about this. Scroll down to the UVB narrowband specification where I marked a *). I try to stick to his suggestions and when I use the lamp 1 minute for my arm and another minute for my leg and another minute for the other leg, I sometimes feel I overdo it and although I don't get sunburn reactions, I do feel and look more flushed and red, so you need to find the right balance. But when I use it for one minute every other day, my skin looks calmer than when I don't use the lamp. A friend uses it as well and he developed a proper skin burn (like a sunburn, marked redness and burning) after using the lap for 3 minutes at close range on one part of skin, so be careful.

And another positive side effect of normal vitamin D levels in the body is that it is supposed to protect you to a degree from cancer

In this link vitamin D is called an anti-angiogenic. It is a well recognized regulator of cell proliferation and differentiation and has the potential to block tumor growth by inhibition of the neoangiogenic process. Sunbathing for hours on end is not a wise idea if you want to protect yourself from getting skin cancer (or wrinkled skin for that matter) but from what I read, sunbathing for a short period of time each day without sunscreen (since that blocks UV absorption and therefore vitamin D production) is not as bad as the cosmetic industries have portrayed it to be for the last decades.  But this probably only applies to those who tan instead of burn in the sun. As each sunburn developed over your lifetime increases the risks of developing skin cancer later on. I am really careful with that, since my uncle suffered from advanced and life threatening skin cancer. But the body also needs sufficient vitamin D levels to fight off all other sorts of other cancers and to maintain a healthy immune system. So it might also be key to sunbathe for a short amount of time and to be vigilant about not developing any form of sunburn. I am lucky that I tan normally on my body and that only my face burns and gets burned easily. If you like to try adding vitamin D to your regime, and don't want to expose your skin to direct sunlight or use a UVB lamp or use supplement pills, there is also a synthetic form of vitamin D available in a cream called Calcipotriene. It may also help to control sebum production and therefore provide some relief for acne sufferers. Apparently vitamin A interferes with vitamin D, so avoid retinols if you decide to give this therapy a go. And If you are interested in vitamin D supplements, you should take a look here. The Canadian Cancer Society now recommends that everyone take vitamin D to prevent cancer. The site has good summaries of the data and offers a new preparation of vitamin D in a micro-pill formulation. The pills have been formulated with cellulose, which absorbs water very quickly. This ensures that the pill breaks up quickly to provide maximum absorption. The micro pill is tiny and tasteless. Many vitamin D pills on the market have very poor dissolution properties, resulting in poor absorption. The site also offers to supply customers with a free supply of 400IU for their children and it also has a good newsletter.

More information about the uvb narrowband 311 nm light device:

Here are some links for the device, and some scientific evidence that it really improves vit D levels:
http://www.uvb-311nm.com/en/5-uvb-na...-for-psoriasis
http://www.uvbnarrowband.com/index.p...vb-narrowband/
http://www.cbc.ca/news/background/he...-d-winter.html
http://www.solarcsystems.com/vitamin...erapy-faq.html

The type of uvb narrowband that I have, has a small wavelength that is optimal for vitamin D production by the skin, with less chance of sunburn. (Source)  "UVB Narrow Band is a subset of the UVB Wideband or Broadband spectrum. The UVB band comprises the range of wavelengths between 290 nm and 320 nm while UVB Narrowband is a "narrow band" of wavelengths centered at roughly 311 nm. UVB Narrow Band UVB is fast becoming the de facto standard in UV Phototherapy for Psoriasis, Vitiligo and Eczema UVB Narrow Band causes less sun burning or erythemal effect than other treatments such as UVB Broadband. The chart above shows that the skin's erythemal (sun burning sensitivity) is at its max at around 297 nm and that UVB NB with it's spectra centered around 311-313 nm generates very low erythemal response. This allows the user to have longer treatment times before "seeing" an erythemal response. UVB NB is fast becoming the recommended treatment to replace Broadband UVB and PUVA. Most of Amjo's sales today are UVB Narrow Band units. Clinical studies have shown that the peak therapeutic effectiveness of UVB to be between 295 to 313 nm and that wavelengths below (shorter) than roughly 300 nm are more likely to cause a strong erythemal response or severe burning. UVB Narrow Band is in the 311-313 nm range and causes less burning than shorter wavelengths."

How effective is UVB light for Vitamin D production?
"If 100% of a person's skin area can be exposed to UVB light, one single dose of sub-erythema UVB (1 MED) can make the equivalent of 10,000 to 25,000 IU of Vitamin D orally. (Holick) Note that it would NOT be advisable to take 1 MED because that dose is too close to burning, and such a large dose is not necessary if regular exposures are taken; but this does show that getting Vitamin D using UVB light is much more effective than getting Vitamin D through diet or supplements. "Sub-erythema" UVB is the dose just slightly less than the dose needed to cause mild skin burning. Erythema is undesirable because it causes patient discomfort, is a major risk factor for skin cancer, and reaching that state does not produce any additional Vitamin D. By irradiating a larger area of skin, a lower dose per unit area can be taken to create the same amount of Vitamin D, thus maximizing Vitamin D production and minimizing the risk of adverse effects. Or, in other words, the cumulative risk is minimized by spreading it over a larger area. Alternatively, if a small phototherapy device is used, treatments can be taken on different parts of the body on alternate days. If the device produces significant quantities of UVA, this may minimize the formation of a tan, which impairs Vitamin D production and forces longer treatment times. If some areas of the body have received significant amounts of cumulative UVB during a patient's lifetime; such as the face, shoulders, upper back, etc.; it is sensible to NOT further irradiate these areas of the body for Vitamin D production. Conversely, using areas that have received very little cumulative UVB during a patient's lifetime are the best sites to use, such as the buttocks.* All assuming again, that burns are strictly avoided.

Research about the UVB lamp and vitamin D3 production
From a study entitled “The Effect of Narrowband UV-B Treatment for Psoriasis on Vitamin D Status During Wintertime in Ireland” To investigate whether the Narrowband UV-B does in fact raise vitamin D levels, researchers followed 60 psoriasis patients during an Irish winter — between October 2008 and February 2009. Half were treated with UVB light therapy three times a week until their psoriasis cleared; the others received no light therapy. Vitamin D levels in the blood were measured along the way. The researchers found that the average patient undergoing UVB light therapy more than doubled their blood levels of vitamin D by the end of the treatment period, which most completed in about 50 days. All of them reached vitamin D sufficient levels, the researchers report in the Archives of Dermatology. As expected, psoriasis also significantly improved with UVB light therapy. Half the patients started out with psoriasis severity scores above 7.1, and by the end of treatment half had scores of 0.5 or below. SOURCE: archderm.ama-assn.org/ Archives of Dermatology, online August 17, 2010.

UVB Exposure May Boost Low Vitamin D
By Kristina Fiore
March 05, 2013
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco.

Narrowband UVB therapy may be a better treatment for vitamin D deficiency than supplementation, Swedish researchers reported here. In a small, single-center study, patients deficient in vitamin D3 who were given 6 weeks of full-body UVB phototherapy had significantly greater increases in serum vitamin D levels than those who took a supplement during that time (P=0.02), reported Morten Bogh, MD, PhD, of Malmö University Hospital in Sweden, during a poster session at the American Academy of Dermatology meeting. However, the results do not mean that patients should turn to tanning beds for UV exposure, Bogh warned. Those machines mostly generate UVA radiation, which doesn't stimulate vitamin D production in the body the way UVB does, he said. "We would not recommend phototherapy as a source of vitamin D to the general population," Bogh said. "Vitamin D deficiency can easily be treated with oral supplementation as shown in this study and several others." "Nevertheless," he said, "it might be a useful alternative for certain groups of patients, especially those with malabsorption problems or noncompliant patients." - To compare narrowband UVB exposure with supplementation for patients with vitamin D deficiency, as measured by serum 25-(OH)D3 levels of 25 nmol/L or less, Bogh and colleagues enrolled 73 patients between February 2010 and May 2011, skipping the summer months of June through September when patients may have had sufficient exposure to the sun. Patients were also excluded if they went on holiday to a sunny location during the course of their treatment. They were randomized to either full-body narrowband UVB radiation three times per week (mean cumulative dose of 9 J/cm2) or to supplementation with 1,600 IU of vitamin D plus 1,000 mg of calcium. A total of 32 patients completed the full 6 weeks of treatment. During that time, the researchers found that patients treated with UVB phototherapy had significantly greater improvements in serum vitamin D levels than those taking supplements, rising from 19.2 nmol/L to 75 nmol/L in the phototherapy group compared with an increase from 23.3 nmol/L to 60.6 nmol/L with supplementation. Bogh concluded that full-body UVB phototherapy thrice weekly is more efficient at raising vitamin D levels than supplementation, but again stressed that it should be reserved for patients with malabsorption problems or noncompliant patients. Jeffrey Miller, MD, of Penn State University in Hershey, Pa., who moderated the session at which the findings were presented, warned that the tanning industry has promoted tanning beds as a way to build healthy vitamin D levels. Bogh pointed out that only 1% to 5% of the UV in tanning beds is UVB. Another audience member agreed that it would be "very dangerous" to misinterpret the findings as a suggestion that indoor tanning could treat vitamin D deficiency. However, future studies could look at using UVB phototherapy that exposes only part of the body to radiation, rather than the whole body."It's well known that you get maximum vitamin D with only your arms exposed for 15 minutes a day," she said. "We don't need to irradiate the whole body." The researchers reported no conflicts of interest. Primary source: American Academy of Dermatology. Source reference: Bogh M, et al "Alternative treatments of vitamin D deficiency".

Another study researched the connection between vitamin D levels and rosacea
In ´The Vitamin D pathway: a new target for control of the skin´s immune response?´, researchers concluded that `Dysfunctional of cathelicidin is relevant in the pathogenesis of several cutaneous diseases including atopic dermatitis where cathelicidin induction is suppressed, rosacea, where cathelicidin peptides are abnormally processed to forms that induce cutaneous inflammation and a vascular response, and psoriasis, where a cathelicidin peptide can convert self-DNA to a potent stimulus of an anti-inflammatory cascade. Recent work has unexpectedly identified vitamin D3 as a major factor involved in the regulation of cathelicin expression. Therapies targeting the vitamin D3 pathway and thereby cathelicidin may provide new treatment modalities in the management of infectious and inflammatory skin diseases.(Source) Here is information about the link between low vitamin D levels and depression and anxiety. iDan also made another interesting post about cytokines and depression/inflammation. And here is a pubmed search on "Vitamin D Pain" as low 25(OH)D levels have been linked to general "musculoskeletal pain", "unusual pain syndrome", "chronic pain", etc. I personally improve my vitamin D levels only slightly, but there is something called Vitamin D toxicity, so don´t overdo it (mainly an issue when someone uses high dosed supplements).

Patients who saw improvement in their rosacea after introducing extra vitamin D

Melissa wrote: I have had rosacea for several years and was diagnosed with Vitamin D defeciency last week. I started taking OTC Vitamin D and within the week noticed a reduction in the redness from my rosacea. Thinking it was due to the Vit. D, I did a search and ended up here. I am very hopeful that I will continue to see improvements!! In the meantime, I will keep using my Finacea and Differen! 

Ken wrote: I started taking vitamin D3 in the form of a tiny gel tab from Costco three days ago. I didn't take it for my rosacea, but I noticed that after only one day, my rosacea had substantially improved. I've learned not to get too excited about this sort of thing, but after only three days and three vitamin D3 tabs later, my symptoms are just about gone. I have a pretty bad case of the condition and so consider this nothing short of a miracle. Hooray!

Julie Kay wrote: I've been lax in taking my vitamins the past couple months; D3 being one of them. I finally reordered and am back on my regimen. I take 4,000 units of D3 a day and have (again) for about two weeks. Reading these comments, I realize my cheeks are less red and lightening to a rosy hue! Brilliant. ~jk

Driven wrote: Much more than 2,000 IU/day of D3 and I get very gradually worse. It's so slow that it's almost unnoticeable. However, 1,000-2,000 IU and careful trigger avoidance works wonders. For me, anyway.

And later: I got worse on 1,000 IU, then improved quite a bit after a few weeks. The same happened when I increased to 2,000. I experience the most benefit from 2,000 IU - any more and the bad effects don't go away. I now consider it one of the most important supplements in my arsenal against rosacea.

Melissa W wrote: I have been taking higher doses of vit D3 for a few years now and I think it helps my overall health and my rosacea but these are just anecdotal findings and not hard facts. As with everything in rosacea it is such an individual response and difficult to generalize so all you can do is read what other people's experiences are and then decide if it is worth trialing yourself. I like to keep my blood levels of D in the 60-90 range and find that taking about 5,000 IU's of D3 helps me do that. As with everything medical though please be sure to OK it with your doctor as the RDA of D3 (I think) is 2,000 max. 

And: I haven't had it checked for at least 6 months but it was in the high 60's at that time. my derm asked that I decrease my vitD3 intake from 10,000 IU's so I take about 5,000 (to 7,000) now but my intake does vary as does my outside exposure to the sun. In the summer I am outside all the time and my vit D levels are higher. I am doing well, thanks for asking. Still on Oracea and still have good days and flares but all in all no complaints. 

And: I think Vitamin D3 has a huge central role in our health and so while its deficiency may not be a cause for rosacea it certainly may play an important role as evidenced by Dan's remarkable change and as far as I know Twickle Purple's improvement. Of course there were other factors at play in their health profile so as MediumDog states it is a generalization and should not be extrapolated from one individual to another. However, I believe that almost everyone can benefit by getting their vit D levels up unless they are already in the desired range. If you read the article courtesy of Dan you will see that the desired level is much higher than previously thought. 

Vicky wrote: My internist recommended I take 2000 mg Vit D per day. My D level is low; it is within the normal range but only by one number-the range starts at 33 and my level is 34. I read (but didn't completely understand)some of the Gallo research and it seemed to indicate that Vitamin D increases the cathelicidin production, which is bad for us, right? However, I talked to my derm and he said if the D level is too LOW it can also interfere with cathelicidin expression. He encouraged me to take the Vitamin D.

Strive wrote: I have to say I feel so much better than I did. It's fairly amazing to me how one little vitamin can have so much impact. Mistica started off with more flushing when she used vitamin D3 supplements but improved later on.  

Patients who saw no improvement or worsening in their rosacea after introducing extra vitamin D

Kip wrote: I had my vit D level tested and went from 25 to around 38 and noticed no difference in redness. For those taking a supplement, vit D can rise pretty quickly so be sure to test now and then to make sure you don't over supplement.

Tmon 912 wrote: Anybody else notice vitamin D3 making their rosacea worse?

Bloem wrote: D3 made me flush like crazy (within a few days of starting it if I remember correctly). I did not have my levels checked. (and:) . I did try 2 different brands. But it got so bad that I stopped taking them and I'm to scared to try again. Things are sort of under control right now.'

V70r wrote: his might interest you. When it comes to vitamin d.... I don't feel like I get flare ups from drinking milk. But if I drink too much milk I might, I have never tried it. But when I take vitamin d3 supplements i really react to it by flaring up. Another thing. I use to work outside in the sun. When I did my rosacea was 100 times better. What does all this mean?? mrsmoof: "I know my rosacea is much better when i am in the sun as well."

MasK wrote: "Some of us like iDan (you can search for his posts) experienced worsening when taking D, then improvements, to the point of total remission. Although some ppl here saw their symptoms worsen, I must say I'm now taking 10 000 IU's (I think you are speaking about international units and not mg) and I don't see much difference, still redness, veins, and flushes. But my gut issues have not been fixed yet. My level of vit D is near 100 and was 10 2 years ago."

Daftpunk wrote: My personal experience has been varied. There was one summer where my face had been flushy for perhaps a few weeks, I started taking 1000 (whatever measurement) vitamin D pills and it cleared it up instantly and it lasted for some time. Right now my face is just getting better after a month of being flushy (it took a mix of oregano oil, peppermint oil, and nicotinamide for a few days and now its looking awesome again.(all oral supps.)) During that month period I tried vitamin D a few times with bad results. Overall, sometimes it helps my redness and sometimes it hurts, it is confusing and tends to make me stick with my bread and butter rosacea supplements. Reading this kind of wants me to try again, might as well, it is healthy after all.

Roz wrote: No can't say that I have noticed much change in the rosacea with the supplementation. I wish I could say there was an improvement. Yet, I will continue with the supplementation for a variety of reasons based on so much that I have read about the beneficial effects of vit d. And, also based on the fact that if I didn't supplement , my vit d level would be too low.

Findingaway wrote: I did experience increased redness and flushing as I increased my dose by 2000 each week to 10,000IU which has subsided a bit now thank goodness.(kept using the vitamin D).

Lookout wrote: Well I tested my reaction to VitD3 again today....I took 2 400iu tablets.....within 20mins my face started burning and it has taken about 6hrs for that to die down.....I seem to have a severe neg reaction to it for some reason while others are taking 1000-2000ius or more w/o any neg reaction.....I am very confused about this....I know some suggest die off but I only took a very small amount so that doesn't make much sense to me. Also took 2 Advil to help....it didn't work for me at all....burning continued.

Phlika29 wrote: When I was taking it I found that my acne, skin texture and KP improved but like lookout it significantly increased my flushing. When I stopped it so did the flushing. In my mind there appeared a clear correlation between taking the tablets and increased flushing. This was about a year or more and so I will buy some more and give it another go.

In a thread called The Truth about vitamin D, on the rosacea forum, Quiller writes about vitamin D 

"Basically, excess vitamin D in the form of 25-D (the storage form) is a bad thing, suppressing the immune system and leading to bacterial infections which suppress the immune system even further: At the moment, most researchers understand that 1,25-D activates the Vitamin D Receptor. However, they are unaware of the models which demonstrate that 25-D has the opposite effect. Consequently, they do not understand that when people start to supplement with extra vitamin D (which is converted into 25-D) the Vitamin D Receptor begins to turn off, not on. L-form bacteria begin to live inside the cells of the immune system and in various tissues. These bacteria create proteins that, just like elevated 25-D, are able to bind and block the Vitamin D Receptor. Together, elevated 25-D and bacterial proteins block the ability of the Vitamin D Receptor to turn on the immune system more than either substance alone. I really don't have any well-formed thoughts about this yet, I just wanted to post it for your consideration. I would also like to know what anyone thinks about the Marshall Protocol. The common denominator in these illnesses is the invasion of white blood cells by tiny cell-wall-deficient bacteria. These bacteria activate the immune cells they penetrate, stimulating production of inflammatory cytokines. Because the bacteria are stimulating the T-helper 1 process of the immune system, the result is called Th1 inflammation.

·   Elevated levels of 1,25-D - the active hormone metabolized from Vitamin D - is a defining characteristic of Th1 inflammation. In healthy people, Vitamin D (25-D) is converted to 1,25-D in the kidneys, where the levels are regulated to match the body's needs. In people with Th1 inflammation, infected white blood cells convert 25-D to 1,25-D independently of the kidneys, causing levels to rise above what the body requires. Elevated 1,25-D makes it easier for the bacteria to move in and out of cells, protecting them from the immune system. As more bacteria are able to parasitize white blood cells, they in turn produce still more 1,25-D. This vicious cycle largely accounts for the chronic nature of Th1 illnesses. There seems to be a crossover between the list of conditions possibly caused by 1) Cpn 2) the NO/ONOO- cycle and 3) Th1 inflammation: Prof. Marshall's papers describe how numerous Th1 diseases such as sarcoidosis, Lyme disease, chronic fatigue syndrome, fibromyalgia, lupus and rheumatoid arthritis (among others) are caused by Cell Wall Deficient (CWD) bacteria of various species." The Truth About Vitamin D: Fourteen Reasons Why Misunderstanding Endures). There is a great video lecture explaining the D3 deficiency at the bottom of a link by Dr. Michael Holick."

  I responded to this threat recently, regarding vitamin D and rosacea
"I also find vitamin D a highly contradicting substance.. Every time I take D supplements (pills, drops, fortified foods) I get massive flushing. But when I sunbathe about an hour or 1,5 hours during midday (only face in the shade), my rosacea calms down enormously. Even people around me can tell and make comments about it. I discussed it with my dermatologist and immunologist and the first said that real sun exposure might be the best way to store vitamin D in the body, as it is the most effective and natural way, your body is exposed to all the right light spectrum rays and pills can indeed cause flushing in fact (I suspect the side products, or the high dose, or the metabolism issues it gives, or it just not being the real natural thing and our bodies not being designed to getting our D's from pharmaceutical pills perhaps?). And the immunologist says that most of his patients with auto immune diseases and inflammation issues in the body have low vitamin D levels. Also his eczema patients for instance. And that in his opinion raising D levels to a normal or higher range will in fact lower overall inflammation. If you are pale and have a skin that easily develops sun burn, this all might be a problem. I only get sunburn on my face, the rest tans immediately, so I sunbathe wherever possible at noon, when the sun is most powerful, for an hour or so and like I said, whenever the sun is out again I nowadays do so much better than in winter. Winter is pure rosacea hell. In terms of skin cancer risk, I asked the docs about this too and you'll get a different answer from anyone you ask most likely, but what I understood, the risks go up whenever you develop sun burns. But vitamin D has proven to protect you to a degree from other forms of cancer and slowly scientists are starting to acknowledge that low vitamin D levels (almost all north western Europeans are deficient at least 8 months of the year) actually exposes us to more risk of cancer. If I were you I would just try out what sunbathing (protect face religiously! And NO sun screen as that will block the skin from the rays and will also block the vitamin D production) does for your overall flushing and inflammation, once the sun is out again :)"

  I am not sure if what Quiller wrote is true, and that storing vitamin D in the body is a bad thing for us
I am not sure if what Quiller wrote is true, and that storing vitamin D in the body is a bad thing for us. I just wonder if lowering the immune system isn´t actually a GOOD thing. I don't know about all the other rosaceans, but my immune system is way too active, overly active, causing extra inflammation and every time my immune system is low, like with flu or illness, my rosacea improves. My derm even used immunosuppressive medication for his most severe rosacea patients and it improved their rosacea drastically from wat he told (bummer the side effects are outrageous). I even read a quite surprising article once about a rosacean who had chemo therapy for cancer and her rosacea improved a lot, probably due to the lowered immune system. Then there are a lot of people who mention increased flushing, especially from the D3 supplements. A lot also write that actual (body) sun exposure in the summer seems to improve matters. I am not sure why this happens. I know that I also flushed more from the D3 supplements but that I seem to lower the redness with conservative use of the uvb narrowband light device. I also am less red in summer when I sun bathe regularly, for about 20 to 30 minutes a day. When I sunbathe longer I get more red. Anyway, the verdict is still out there but there seems no harm in trying vitamin D supplements in whatever form for yourself.. Wishing you all a happy Christmas with lots of snow and a healthy New Year! 

  Here are  links to some interesting forum discussions about vitamin D and sun exposure versus rosacea

The vitamin D dilemma

The role of vitamin D in controlling skin inflammation

Who had vitamin D levels checked?

Vitamin D and cathelicidin

Vitamin D3 50000 IU supplements

Does Vitamin D create more of the cathelicidins that cause rosacea

Possible negative effects of high dose Vitamin D

Vitamin D3 and Rosacea

My Vitamin D3 Story
The vitamin D dilemma
Does Vitamin D make you worse

            

Update December 20th 2013

In this article, it is stated that: "Vitamin D influences more than 200 genes. This includes genes related to cancer and autoimmune diseases like multiple sclerosis. Vitamin D affects your DNA through the vitamin D receptors (VDRs), which bind to specific locations of the human genome.

 “Vitamin D deficiency is a well-known risk factor for rickets, and some evidence suggests it may increase susceptibility to autoimmune diseases such as multiple sclerosis (MS), rheumatoid arthritis and type 1 diabetes, as well as certain cancers and even dementia.”

"Reuter’s information is actually a bit misleading as other scientists have identified a total of nearly 3,000 genes that are upregulated by vitamin D. The particular study referenced above identified 200 genes affected, but it’s not clear if that is in addition to the ones already identified, or if they simply confirmed many of the ones found by others. One thing’s for sure: Vitamin D is one of the major keys for disease prevention and for optimal health. In recent years vitamin D has emerged as a star of the “vitamin” world. For example, there are currently over 800 studies showing vitamin D’s effectiveness against cancer. Optimizing your vitamin D levels can literally cut your risk of several cancers by 50 percent. Further, middle aged and elderly people with high levels of vitamin D could reduce their chances of developing heart disease or diabetes by 43 percent."

How Does Vitamin D Do What it Does?

"Vitamin D is actually a “prohormone,” which your body produces from cholesterol. Because it is a prohormone, vitamin D influences your entire body -- receptors that respond to the vitamin have been found in almost every type of human cell, from your brain to your bones. So what modern science has now realized is that vitamin D does more than just aid in the absorption of calcium and bone formation, it is also involved in multiple repair and maintenance functions, touches thousands of different genes, regulates your immune system, and much, much more. Just one example of an important gene that vitamin D up-regulates is your ability to fight infections, as well as chronic inflammation. It produces over 200 anti microbial peptides, the most important of which is cathelicidin, a naturally occurring broad-spectrum antibiotic. This is one of the explanations for why it’s so effective against colds and influenza. In addition, since vitamin D also modulates (balances) your immune response, it can prevent an overreaction in the form of inflammation, which can lead to a variety of autoimmune disorders, such as Crohn’s disease for example. When you consider the fact that you only have about 25,000 genes in your body, and vitamin D has been shown to influence nearly 3,000 of them, the bigger picture of its true impact on your health can be easily understood. It may, in fact, have literally thousands of health benefits! However, it’s also very clear that unless you have taken specific measures to address it, the odds are overwhelming that you are deficient in this important nutrient."

Are You Vitamin D Deficient?
"Vitamin D deficiency is a growing epidemic across the world and is contributing to many chronic debilitating diseases. There are a few reasons for this trend. First, most people spend far too much time indoors during daytime hours. You may also have also been seriously misled by “expert’” recommendations to avoid all sun exposure, and to slather yourself with sunscreen whenever you do go outside. Please understand that sunscreen will virtually eliminate your body’s ability to produce any vitamin D because it blocks the UVB radiation that causes your skin to produce it naturally. As a result, in the United States the late winter average vitamin D is only about 15-18 ng/ml, which is considered a very serious deficiency state. In fact, new studies show that about 85 percent of the U.S. population is vitamin D deficient. This is primarily related to the recent appreciation that your levels of vitamin D should be MUCH higher than previously thought. Consider the following vitamin D facts:

• Vitamin D deficiency is epidemic in adults of all ages who have increased skin pigmentation, such as those whose ancestors are from Africa, the Middle East, or India, who always wear sun protection, or who limit their outdoor activities.
• African Americans and other dark-skinned people and those living in northern latitudes make significantly less vitamin D than other groups.
• 60 percent of patients with type 2 diabetes have vitamin D deficiency.
• Studies showed very low levels of vitamin D among children, the elderly, and women.
• One nationwide study of women revealed that almost half of the African American women of childbearing age might be vitamin-D deficient.

Winter, when sun exposure is at its lowest, is the time of year when you need to be most concerned about the amount of vitamin D you are receiving, as your vitamin D levels can drop by up to 50 percent in the winter. Of course, if you have the tendency to spend the summer months indoors, out of the sun, or you only go outside with sunscreen on, then you would need to be concerned during the summer months as well."

Health Benefits of Vitamin D

"It’s absolutely tragic that dermatologists and sunscreen manufacturers have done such a thorough job of deterring people from the sun -- your optimal source for natural vitamin D. Their widely dispersed message to avoid the sun as much as possible, combined with an overall cultural trend of spending more time indoors during both work and leisure time, has greatly contributed to the widespread vitamin D deficiency seen today -- which in turn is fueling an astonishingly diverse array of common chronic diseases, including:

Cancer	Hypertension	Heart disease
Autism	Obesity	Rheumatoid arthritis
Diabetes 1 and 2	Multiple Sclerosis	Crohn’s disease
Cold & Flu	Inflammatory Bowel Disease	Tuberculosis
Septicemia	Signs of aging	Dementia
Eczema & Psoriasis	Insomnia	Hearing loss
Muscle pain	Cavities	Periodontal disease
Osteoporosis	Macular degeneration	Reduced C-section risk
Pre eclampsia	Seizures	Infertility
Asthma	Cystic fibrosis	Migraines
Depression	Alzheimer’s disease	Schizophrenia

Vitamin D Against Cancer
A study by Dr. William Grant, Ph.D., internationally recognized research scientist and vitamin D expert, found that about 30 percent of cancer deaths -- which amounts to 2 million worldwide and 200,000 in the United States -- could be prevented each year with higher levels of vitamin D. Other studies showed that you can decrease your risk of cancer by more than half simply by optimizing your vitamin D levels with sun exposure. Vitamin D has a protective effect against cancer in several ways, including:

• Increasing the self-destruction of mutated cells (which, if allowed to replicate, could lead to cancer)
• Reducing the spread and reproduction of cancer cells
• Causing cells to become differentiated (cancer cells often lack differentiation)
• Reducing the growth of new blood vessels from pre-existing ones, which is a step in the transition of dormant tumors turning cancerous

When is the Best Time to Go Out in the Sun, and for How Long?
The optimal time to be in the sun for vitamin D production is as near to solar noon as possible. That would be between roughly 10:00am and 2:00pm. During this time you need the shortest exposure time to produce vitamin D because UVB rays are most intense at this time. Plus, when the sun goes down toward the horizon, the UVB is filtered out much more than the dangerous UVA. When you’re out in the sun, be very careful about the length of your exposure. You only need enough exposure to have your skin turn the lightest shade of pink. This may only be a few minutes for some. Exposures any longer than this will not produce any more vitamin D but will accelerate photo aging and increase your risk for non-melanoma skin cancers like basal and squamous cell cancers. Once you reach this point your body will not make any additional vitamin D and any additional exposure will only cause harm and damage to your skin. Most people with fair skin will produce the maximum amount of vitamin D in just 10-20 minutes, or, again, when your skin starts turning the lightest shade of pink. Some will need less, others more. The darker your skin, the longer exposure you will need to optimize your vitamin D production. African-Americans need perhaps 20 percent more sun exposure time than whites. And contrary to popular opinion, your body simply cannot make adequate vitamin D from the sun unless you have more skin area exposed than just your face and hands. In fact, at least 40 percent of your body should be uncovered to optimize your vitamin D production. Another option is to use a safe tanning bed, again paying attention to not getting burned."

New Way to Protect Against Sunburn
"A few months ago I found out that a carotenoid extracted from algae called astaxanthin can be extremely useful in preventing and eliminating sunburn.  Interestingly, this is the antioxidant in krill that prevents it from being damaged. What current research is showing is that if you are on 2 mg of astaxanthin for a month, it becomes very difficult to get sunburned. Additionally, it also appears to prevent the development of the most common form or blindness, age-related macular degeneration, as well as cataracts, and most likely protects you from EMF when you are flying or being exposed to diagnostic X-rays. The key though is that it takes weeks to build up in your tissues, so you  can’t just swallow a few pills prior to your exposure and expect to receive any benefit. Astaxanthin is also fat soluble and needs to be taken with some fat or you simply won’t absorb it."

Vitamin D Supplements: How Much Should You Take?
"It is wise to consider oral vitamin D3 supplementation during the winter months, or year-round if you haven’t time or sufficient access to the sun or a safe tanning bed. However, the Reuter’s article above is years behind the research on their recommended dosage of 1,000 IU’s a day. It’s true, there are no definitive studies on the optimal daily dose of vitamin D, but based on studies on healthy indigenous peoples, many vitamin D experts now agree that most adults, including pregnant women, require about 5,000 IU of vitamin D daily for optimal health – or 35 IU’s of vitamin D per pound of body eight, which is certainly well above the current RDA. That said, although these recommendations may put you closer to the ballpark of what most people likely need, it is impossible to make a blanket recommendation that will cover everyone’s needs. The ONLY way to determine how much you might need is by testing your blood level of vitamin D. This is in fact a very important aspect of optimizing your vitamin D levels that you should not skip over. Why? Because while overdosing on vitamin D from sun exposure is highly unlikely as your body has a built-in “failsafe” feedback loop, which will tend to shut down production when your levels are healthy, it IS possible to overdose when taking supplements. So you need to be careful when using oral vitamin D therapy and make certain you have your blood levels checked. Many of you may choose to ignore this warning, but I am telling you in no uncertain terms that while vitamin D has enormous potential for improving your health, it has significant potential to worsen it, if you use it improperly.

What Vitamin D Level do You Need to Stay Healthy?
The OPTIMAL value of vitamin D that you’re looking for has recently been raised to 50-70 ng/ml, with even higher recommended levels required for more serious disease prevention, as shown in the chart below. I hope you can see now some of the many benefits of vitamin D, and why it is so critical to make sure you and your family maintain healthy levels at all times. Please take this opportunity to use one -- or more -- of the options I’ve suggested for getting your daily dose of vitamin D. Optimal vitamin D, however you get it, can literally make the difference between a lifetime of chronic disease and one of vibrant health and vitality. For even more information about this essential nutrient, please peruse the links below.

On a side note, the link between autoimmune disease and cancer risk (link):

Autoimmune Diseases Affect Cancer Risk

No. 54 | 10/10/2011 | by Kün / Koh

In a recently published study, scientists of the German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ) have calculated the interrelations between autoimmune diseases and cancer of the digestive tract. They discovered that many autoimmune diseases increase the cancer risk, while others, such as rheumatism, are associated with a significantly lower bowel cancer risk. These differing impacts on cancer risk may be attributable to the medications administered. In some autoimmune diseases antibodies turn against the body’s own structures. An association between autoimmune diseases, in which the immune system attacks the body's own structures, and a higher risk of getting cancer has long been suspected. Kari Hemminki, an epidemiologist at DKFZ, has now studied, jointly with colleagues from Sweden, this interrelation between 33 different types of autoimmune disease and 11 different types of cancer of the whole digestive tract (oral cavity, esophagus, gastrointestinal tract, liver, and pancreas). It turned out that most autoimmune diseases increase the cancer risk in those affected. A possible cause of the increase or decrease in cancer risk of patients  with autoimmune diseases is medication: Many of these diseases are being treated by immunosuppressive drugs. Thus suppressed, the immune system is no longer capable of efficiently fighting tumor cells. This results in a higher cancer risk. Anti-inflammatory drugs, however, may lower the risk of getting cancer. Thus, it was shown that aspirin agent ASS, which is contained in many antirheumatic drugs, can prevent cancer. Most people with rosacea don't take immuno suppressive medication and some rosacea patients have underlying autoimmune diseases and an overtly active immune system. Today, December 20th 2013, news broke that there is a new cancer treatment, where people's  immune system gets activated strongly and this helps so far about 25% of patients. I wonder if patients with an overtly active immune system have less cancer risk therefore.

June 20th 2014

I received a very interesting email:
"First just wanted to say you did a great job with the comprehensive write up on Vit D, and its possible effects on rosacea. I just wanted to give you my experience as I am quite convinced it is relevant to your write up. I am a 32/M. Never had any serious health issues. About 3 or 4 mos ago I developed angular chilitis. It was clear to me what it was so I did research to try to find the cause. Vit D deficiency was my top guess as I don’t eat anything that contains Vit D and my irish skin makes me stay out of the sun as much as possible. So I get tested for Vit D deficiency and I had a level of 6. I have never had rosacea symptoms in my life but would get flush every once and awhile if I worked out hard, but not often. I was given 50k unit megadoses which I was to take for 8 weeks. Less than 1 week in I had CONSTANT flushing. I thought it was awfully strange that it started right after, but kind of just hoped it would go away and knew I had to take it because my levels were so low. 2 wks later the flushing clearly started showing all classic signs of rosacea (never had a mark on face before). Rosacea does run in my family though. There is NO question in my mind the vit D triggered my rosacea symptoms. There's just no other explanation as to how I would go from having ZERO sign of rosacea, to a rapid development of it, at the EXACT same time I started taking the megadoses. I have also read the study and the HIGH correlation of increased serene protease and cathelicidine in rosacea patients, and the fact that VIT D supplementation increases this production makes it even more unlikely its a coincidence. I also find it too coincidental that the sun is such a huge trigger for rosacea patients, and that I have become ULTRA photosensitive ever since. It is curious that some people improve by taking VIt D, but I think it probably has to do with each individual person and the amount of IU the person is taking. Just wanted to let you know my personal Vit D experience and that its triggering of flushing/rosacea symptoms is undeniable! hope its useful :)"

I replied: "Thank you! That was an interesting read. Would you mind if I share it in the blog post on Vit. D? Its interesting as you were flush free prior to starting the D injections and it sounds pretty plausible that it immediately responded to it. I never really believed the big hype that was going on a few year ago, when everybody on the rosacea forums swore by vitamin D pills. I mean, I never believed that this vit. D supplementation would be problem free for bad flushers, ultimately. Like you, I get severe flushing from even half a D3 tablet. I notice that when I sunbath, say longer than 30 minutes, I get more easily flushed at first. But in the long run, I feel I am less red and less inflamed when I build up a bit of a tan. I'm so much more ruddy red and raw skinned in winter. So am still pretty confused about how all this exactly works, apart from the good point you make on the protease and cathelicidin. Mega doses of D3 supplementation does seem a potential flare-up trigger and maybe this is because they immediately kickstart huge cathelicidin induced inflammation. It is clear as day to me that high doses of vit. D supplements really sets my rosacea off badly, and probably for these chemicals that cause instant vasodilatation. I just fear that being severely low on D3 levels, as we are, will in the long run also cause immune related issues and inflammation. As my prof said, to lower inflammation in auto immune disease, they always suggest upping the vit. D to acceptable levels. However, those patients don't typically deal with hypersensitive facial blood vessels.... Awful that this seems to have triggered your rosacea. I do believe however that for ppl like us, with the predisposition and the genetic make up for rosacea, it could be a lot of different things that trigger it into full bloom. I always wondered, what if.. if I had never used the cortisone cream? By now I am convinced I would have developed the rosacea then anyway, maybe a year or ten more down the line, from hormonal changes, or stress, or whatever. Maybe this is the case with you too, or maybe vitamin D can actually cause rosacea in some? What are your thoughts on this? Best wishes Nat"

"Hi...Yes you may post my comment as long as don’t use my name or email. I think its a legitimate concern people should know about. I agree its a tough position to be in, even if I knew this was a risk. I was def experiencing bone pain, and probably would have been scared into taking it anyways. However, knowing what I know now after researching, I would have never taken such high megadoses. The truth is most doctors don’t have much of a background in vitamins. And even if they do, like most other things, they aren’t going to tell you anything that's not in their little book that deviates from the "standard of care" because these days everyone would sue unfortunately. So basically if you have a symptom, and 50% of the people with that symptom have a certain illness….that's what you have. I always thought docs knew everything but obv I learned that's not true early on. The good ones should keep up on new research and have a hunger to learn everything, the bad are just narcissistic and think they already know everything. Experience is huge imo. You can be the smartest person on earth but nothing can replace experience, and having seen the issue before. But with experience and knowledge also comes narcissism and stubbornness. My vit D levels are finally above 20 so I’m thinking bout stopping and trying to just get more natural sun. I stopped the 50k megadoses after 4 wks but I have been taking 1000-2000IU/day liquid until I got up to 20. Im hoping I didn’t trigger something permanent but who knows. Did you have a decrease in flushing when you stopped the Vit D supplements? It makes sense that its not in our genetics to be taking artificial doses. Pretty sure our ancestors didn’t use that crap ;) Plus the whole idea of vit deficiencies having such an impact on our bodies is relatively new so there's no way they know what some of these megadoses do….esp long term. That's why I’m so hesitant to take anything new. Its like, you’ve tested it for 5 yrs how do you know what it does to me 20 yrs from now! :) oh ok ill take the company selling its word for it, sounds good :p That study seems seems pretty conclusive to me, I mean every person with rosacea had elevated amounts of sp and c. But I don’t see any more research into it. The wheels in the medical world def turn slow."

"Thanks heaps, very good mails. I find that with me, the increased flushing and redness wears off after taking vitamin D supplements. But I think I read vit D is stored in your fat reserve. Yeh it is this. When you take a mega dose, I assume it is stored and it is not a quick matter of time before you flush it out, like is the case with many other supplements. So the side effects might linger, as the body breaks the reserve down slowly. Hence why I only sunbath a short period of time and try to add a steady and slow stream of vitamin D to the body, but in very low numbers. When I am still more flushed the next days, I don't go in the sun. I am not sure if the body breaks down supplemental vitamin D in the same way as it does natural made vitamin D through sun exposure. The body produces its own vit. D after sun exposure, and when you take pills (or foods like eggs and fish), the body first needs to transform it. Yeh I know... Seen so many derms who only came up with 'Yeh it's rosacea' and 'all we can prescribe are antibiotics and a cream'. For the flushing subtype 1 they tend to have very little, if any, treatment suggestion. I'm happy so many people have visited Prof Chu over the years, all the feedback I got was very positive, a great derm who does think outside the box and takes all sorts of underlying diseases and problems into consideration and has a range of treatment options, albeit even those are limited at some point Wished there was a cure! But the let down from doctors is indeed extremely demoralizing. You'd think they would help with the pain but there are limitations to what they know and can do about it, and with little profits to be made over a cure, I am afraid that we will have to wait a whole lot longer before anything really progressive is discovered for rosacea, apart from a new pill or cream that will temporarily suppress some symptoms and keeps you hooked for life :( "

It's my understanding that doctors are now suggesting Narrowband UVB phototherapy over Broadband UVB phototherapy for various skin issues, including eczema, because they believe in the long run that the Narrowband will be found to be less dangerous than Broadband. According to Dr. Elizabeth Page, MD, a dermatologist at the Lahey Clinic and an instructor in dermatology at Harvard Medical School in Boston: "Narrowband UVB uses a very small part of the UVB spectrum, which cuts down on exposure to UV radiation." http://www.everydayhealth.com/eczema/light-therapy.aspx That sure sounds like a good thing. So it made me wonder if we would still be able to get Vitamin D from the Narrowband UVB. The answer appears to be "Yes". In fact, the below study found that "Narrowband UVB therapy may be a better treatment for vitamin D deficiency than supplementation." However, just like everything, there are caveats. All the best! Janet (NJ)

February 27th 2015

On a facebook page for rosacea, some people mentioned vitamin D supplements making them flushed: "I never normally flush.....Been flushing since yesterday...... only new thing is vitamin d :( " 

Response:  "I stopped taking vitamin d too!-It can take up to a month to get out system  I'm sitting with cold cloth on my face just now :( -I think my rash started when i started taking calcium and vitamin d, never clicked the two might be linked until last month! Still got redness but no rash! Don't know whether its a coincidence or what! -Yes Vitamin D also makes me flush more :("